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Psychological Trauma: Theory, Research,
Practice, and Policy
Posttraumatic Stress Disorder, Anxiety and Depression
Symptoms, and Psychosocial Treatment Needs in
Colombians Internally Displaced by Armed Conflict: A
Mixed-Method Evaluation
Anne Richards, Jorge Ospina-Duque, Mauricio Barrera-Valencia, Juan Escobar-Rincón, Mario
Ardila-Gutiérrez, Thomas Metzler, and Charles Marmar
Online First Publication, April 11, 2011. doi: 10.1037/a0022257

CITATION
Richards, A., Ospina-Duque, J., Barrera-Valencia, M., Escobar-Rincón, J., Ardila-Gutiérrez, M.,
Metzler, T., & Marmar, C. (2011, April 11). Posttraumatic Stress Disorder, Anxiety and
Depression Symptoms, and Psychosocial Treatment Needs in Colombians Internally
Displaced by Armed Conflict: A Mixed-Method Evaluation. Psychological Trauma: Theory,
Research, Practice, and Policy. Advance online publication. doi: 10.1037/a0022257
Psychological Trauma: Theory, Research, Practice, and Policy © 2011 American Psychological Association
2011, Vol. ●●, No. ●, 000 – 000 1942-9681/11/$12.00 DOI: 10.1037/a0022257

Posttraumatic Stress Disorder, Anxiety and Depression Symptoms, and

Psychosocial Treatment Needs in Colombians Internally Displaced
by Armed Conflict: A Mixed-Method Evaluation

Anne Richards Jorge Ospina-Duque, Mauricio Barrera-Valencia,

University of California, San Francisco Juan Escobar-Rincón, and Mario Ardila-Gutiérrez
Universidad de Antioquia

Thomas Metzler Charles Marmar

University of California, San Francisco New York University Langone School of Medicine

Armed conflict in Colombia has resulted in the displacement of an estimated 4.5 million people, or about
10% of the Colombian population. Hundreds of thousands of Colombians are exposed to violence and
forced displacement annually. The present study used survey methods to assess levels of posttraumatic
stress disorder (PTSD), depression, and anxiety symptoms in a convenience sample of 109 internally
displaced adults residing in Medellı́n, Colombia. A qualitative approach including an open-ended survey
and focus groups with a subsample of 44 survey respondents was used to gain a better understanding of
mental health treatment needs. A large proportion of survey respondents exceeded cut-scores for
clinically significant PTSD (88%), anxiety (59%), and depression (41%). Multivariate regression models
showed that female gender was a significant predictor of higher PTSD symptom levels and that female
gender, higher education, and being separated as opposed to married predicted higher levels of depression
symptoms. Focus group findings suggest that participants are interested in specialized psychological
treatments as well as broader psychosocial interventions to treat the consequences of exposure to violence
and forced displacement.

Keywords: PTSD, internally displaced people, armed conflict, cross-cultural psychiatry, Colombia

Globally, civilian populations are the primary victims of armed
conflicts between and across national borders. Forced displace-
ment of civilians within the borders of their country is an all too
common result of armed conflict. Colombia is the only country in
the Western hemisphere where internal displacement of the civil-
ian population continues to occur on a massive scale. In Colombia,
guerrilla, paramilitary, and government forces fight for territory in
a complex struggle involving drug lords and other parties inter-
ested in Colombia’s valuable natural resources. Over the last four
decades, this conflict has resulted in the displacement of an esti-
mated 4.5 million people, or about 10% of the Colombian popu-
lation (Internal Displacement Monitoring Centre, 2009). Accord-
ing to both government and nongovernmental organization (NGO)
sources, between 200,000 and 400,000 individuals were forcefully
Anne Richards and Thomas Metzler, Department of Psychiatry, Uni-
versity of California, San Francisco; Jorge Ospina-Duque, Mauricio
Barrera-Valencia, Juan Escobar-Rincón, and Mario Ardila-Gutiérrez, De-
partment of Psychiatry, Universidad de Antioquia; Charles Marmar, De-
partment of Psychiatry, New York University Langone School of Medi-
cine.
Correspondence concerning this article should be addressed to Anne
Richards, Department of Psychiatry, University of California, San Fran-
cisco, CA, San Francisco VA Medical Center, 4150 Clement Street, Box
116C, San Francisco, CA 94121. E-mail: anne.richards@ucsf.edu
displaced annually between 2001 and 2005, and there is no evi-
dence of decrease in rates at this time.
Internally displaced people do not benefit from the same
statutes that protect and assist refugees. As such, it is the
responsibility of the national government to protect and assist
internally displaced people. Despite progress in legislation pro-
tecting internally displaced Colombians, access to basic re-
sources such as food, shelter, education, and medical care has
remained poor. Access to mental health treatment is virtually
nonexistent (Mogollón-Pérez & Vázquez, 2008; Mogollón
Pérez & Vázquez Navarrete, 2006).
It is imperative to understand the nature of the psychological
distress of internally displaced people to develop appropriate
evidence-based interventions. Although prevalence rates vary
widely between studies, PTSD and depression appear to affect a
significant number of individuals exposed to armed conflict and
displacement (Steel et al., 2009). There are data supporting high
rates of general anxiety and depression symptoms in internally
displaced people in Colombia (Caceres, Izquierdo, Mantilla, Jara,
Velandia, 2002; Puertas, Rios, & del Valle, 2006). There is also
preliminary evidence of high rates of PTSD in civilians directly
affected by the armed conflict (Pineda, Guerrero, Pinilla, & Estu-
piñán, 2002; Sistiva-Castro & Sabatier, 2005).
To develop appropriate and acceptable interventions, it is also
imperative to understand whether internally displaced people are
interested in treatment for depression, general anxiety, PTSD, or

1
2 RICHARDS ET AL.
other psychosocial sequelae of violence and displacement. There
has been considerable debate about whether Western diagnostic
constructs and symptoms reflect distress experiences that are rec-
ognized and prioritized by non-U.S. and non-European individuals
as deserving of treatment. Diagnosing PTSD and implementing
“trauma-focused” treatments have been particularly targeted as
potentially inappropriate in non-U.S. and non-European popula-
tions (Bracken, Giller, & Summerfield, 1995; Bryant & Njenga,
2006; Johnson & Thompson, 2008; Summerfield, 1999). Oppo-
nents to the wide-spread application of trauma-focused treatments
argue that the focus on PTSD symptoms and their treatment
represents an ethnocentric mentality that unnecessarily “medical-
izes” distress and distracts from a more appropriate focus on
recovery at the level of the social network (Miller, Kulkarni, &
Kushner, 2006). An alternative perspective is that evidence-based
trauma-focused therapies should be provided whenever possible to
individuals who endorse trauma-related psychological symptoms,
consider them germane to their experience, and consider them a
priority for treatment.
Catering to individual treatment needs also requires identifying
differences in trauma response among different demographic sub-
groups (U.S. Department of Health and Human Services [DHHS],
2001). Research in the U.S. demonstrates that women may be more
at risk of PTSD, depression, and anxiety than men (Brewin,
Andrews, & Valentine, 2000; Kessler et al., 2005; Tolin & Foa,
2006). Findings from large epidemiological samples across Latin
America and in Colombia also suggest that women experience
higher rates of anxiety, depression, and PTSD than men do (Kohn
& Rodrı́guez, 2009; Posada-Villa, Aguilar-Gaxiola, & Deeb-
Sossa, 2009).
Differences between racial and ethnic subgroups have not been
closely studied in Colombia. The lack of attention to ethnicity and
racial differences in health status is reflected in the Colombian
census, which did not include a comprehensive assessment of race
and ethnicity in its population estimates between 1912 and 2005.
Research in U.S. populations has provided mixed findings regard-
ing differences in rates of mood and anxiety disorders between
Caucasians and minority groups (DHHS, 2001). Researchers who
have identified differences have proposed a range of factors that
could account for them, including differences in exposure rates,
socioeconomic status, social and cultural factors, and perceived
discrimination (DHHS, 2001; Hunter & Schmidt, 2010; Pole, Best,
Metzler, & Marmar, 2005; Pole, Gone, & Kulkarni, 2008). The
U.S. Central Intelligence Agency has compiled a demographic
profile for Colombia which indicates that mestizos, who are pri-
marily of Amerindian and White European descent, comprise
about 58% of the Colombian population, individuals with Afro-
Colombian ancestry comprise about 20% of the population, Euro-
pean Whites comprise about 20% of the population, and Amerin-
dians comprise about 2% of the population (Central Intelligence
Agency, 2009). Despite the paucity of attention to race and ethnic
differences in health outcome, there is ample evidence that darker
skin and membership of Afro-Colombian and Amerindian heritage
is associated with greater economic, political and social margin-
alization, either as a result of racial discrimination or due to greater
representation in rural areas that are most exposed to violence and
least protected by federal law (Wade, 1995). In line with this,
Amerindians and Afro-Colombians are at increased risk of forced
displacement ( Departamento Administrativo Nacional de
Estadı́sticas, 2007). It is not known how ethnoracial status con-
tributes to differences in health outcomes in Colombians affected
by the armed conflict. Identifying such differences, should they
exist, is crucial for developing appropriate and acceptable
evidence-based treatment interventions.
Present Research
The goals of the present study are twofold. The first is to
determine levels of PTSD, depression and anxiety symptoms, and
the demographic correlates of these symptoms in a heterogeneous
sample of internally displaced adults residing in Medellı́n, Colom-
bia. An additional goal is to gain a better understanding of the
types of interventions acceptable to this subset of internally dis-
placed Colombians for the treatment of mental health problems
associated with violence and forced displacement.
Method
Participants
One hundred nine participants were recruited at the Unidad de
Atención y Orientación a la Población Desplazada (UAO) in
Medellı́n, Colombia. The UAO is the service center to which
internally displaced people in Medellı́n must present to obtain
access to government-funded health care. It is also their official
resource for food and shelter support and for information and
referrals to health, legal, and human rights services. At the time of
data collection, the center was co-administered by an NGO and the
city government of Medellı́n. Internally displaced people who
report their status as such are referred to this center by city officials
and/or via word-of-mouth. The study group was a sample of
convenience recruited at UAO orientation meetings, which all new
service-seekers at the UAO are required to attend. Seven such
meetings took place over a 3-week period in May and June of
2008. Individuals 18 years or older were invited to participate.
Although the percentage of those invited who agreed to participate
is unknown, the rapidity of recruitment indicated that the majority
of invitees chose to enroll in the study.
Procedure
After informed consent procedures, participants completed a brief
demographics questionnaire and self-report questionnaires assessing
PTSD, depression, and anxiety symptoms. They also completed a
questionnaire about the relevance of the PTSD questionnaire to their
experience. Illiterate individuals and those requesting assistance com-
pleted all questionnaires with the help of research staff. Participants in
the survey segment of the study were invited to participate in the
second component of the study, consisting of focus groups. Seven
focus groups were created. Groups were formed along gender and
ethnoracial status lines based on the researchers’ interest in under-
standing how violence and displacement experiences might differ
between men and women and Afro-Colombians and mestizos (dis-
cussed elsewhere). Ethnoracial status was determined by participants’
self-identification as “Afro-Colombian,” “mestizo,” or “other.” Given
the low representation of indigenous individuals in Medellı́n, this
category was not identified separately. Only two individuals self-
identified as “other.” Forty-four individuals participated in focus
 PSYCHOSOCIAL SEQUELAE OF CONFLICT IN COLOMBIA
groups. Not all participants in the survey segment of the study par-
ticipated in the focus groups, primarily due to group size limitations,
and all participants in the surveys were invited until the focus group
size limitations were met (eight participants maximum). Focus groups
were conducted at the university hospital of the University of Antio-
quia, in the Department of Psychiatry. Focus groups were conducted
by the co-Principal Investigator (PI), who is from the United States
and proficient in Spanish, and a Colombian psychologist from the
University of Antioquia with several years’ experience working with
victims of the armed conflict in Colombia.
The focus groups consisted of discussions about the effects of
displacement and its precipitants on internally displaced people.
The participants were informed that there was no obligation to
talk about their particular experience but that we would like
them to talk about what they observe in their families and other
internally displaced people they know. The goal in utilizing this
approach was to gather information about the experience and
treatment needs of internally displaced people without partici-
pants feeling threatened or overly exposed. After an open-ended
discussion of the mental health consequences of displacement,
participants were asked “To whom would you go, or to whom
would you refer a friend or a family member, who is suffering
from some of the problems you have discussed so far?” After an
open-ended discussion, participants were asked more specifi-
cally whether they thought internally displaced people would be
interested in and could benefit from various forms of psycho-
education and treatment, including treatment with a psycholo-
gist or psychiatrist, psychoeducational materials, video and/or
radio presentations, and Internet-based psychoeducation and
treatments. The list of treatments proposed was developed over
the course of the study based on suggestions made by group
members in prior groups.
Measures
Demographic information. Prior to completing the mental
health assessments, participants completed a brief demographic
survey. Variables included age, gender, marital status, ethnoracial
status, educational attainment, time since arrival in Medellı́n, and
current employment status. Marital status categories included mar-
ried, divorced, widowed, single, and domestic partnership, the
latter being a very common arrangement in Colombia.
PTSD. We used a 24-item checklist developed and validated
by Colombian investigators Pineda et al. for the assessment of
PTSD (Pineda et al., 2002). The authors validated the question-
naire using SCID-I semi-structured clinical interviews (First,
Spitzer, Williams, & Gibbon, 1999) in a Colombian town popu-
lation that had been partially destroyed by a guerrilla attack.
Distinct from the PTSD Checklist (Weathers, Litz, Herman,
Huska, & Keane, 1993), the items in this checklist were written in
Colombian Spanish to reflect the criteria for PTSD as described in
the standard Spanish language version of the DSM–IV–TR (Amer-
ican Psychiatric Association, 2002). Thus, the first two items
reflect criteria A1 and A2, items 3–7 reflect the cluster B criteria,
items 8 –14 the cluster C criteria, items 15–19 the cluster D
criteria, and items 20a-20d reflect impairment in occupational and
social functioning. A subject’s level of endorsement for each stated
experience or symptom is indicated on a 4-point Likert-type scale.
In a validation study, a cut-off score of 51 was associated with
3
76.3% sensitivity, 84.4% specificity, 74.4% positive predictive
value, and 85.7% negative predictive value for the diagnosis of
PTSD (Pineda et al., 2002). Cronbach’s alpha was 0.91 for the
current sample, indicating high internal consistency.
Anxiety symptoms. The Zung Anxiety Scale was utilized to
assess levels of anxiety symptoms (Zung, 1971). This measure has
been used by the World Health Organization in global health
research and was previously utilized in a large epidemiological
study of general health in internally displaced people in Colombia
(Caceres et al., 2002). The Zung Anxiety Scale consists of 20 items
reflecting common symptoms of anxiety, including numerous so-
matic symptoms often accompanying anxiety. This scale measures
symptomatology using a 4-point Likert-type scale indicating fre-
quency at which subjects experience the symptom described in
each item. Scores between 45 and 59 reflect mild to moderate
levels of anxiety, scores above 60 generally reflect marked and
severe anxiety, and scores above 75 reflect extreme levels of
anxiety.
Depression symptoms. The Zung Depression Scale, which
consists of 20 items reflecting common symptoms of depression
(Zung, 1965), was utilized to evaluate participants for depression.
It has been used and validated in Colombian Spanish-speaking
populations (Caceres et al., 2002; Dı́az, Campo, Rueda, & Barros,
2005). As with the Zung Anxiety Scale, it measures symptoms on
a 4-point Likert-type scale. Based on the original validation study,
scores of 50 or greater were associated with clinically significant
depression. Scores between 50 and 59 are generally understood to
represent mild depression, scores between 60 and 69 moderate
depression, and scores 70 and above severe depression.
Relevance of PTSD survey to participant experience. In
order to gauge the relevance of the PTSD checklist symptoms to
the participants’ experience, the researchers developed a PTSD
Checklist Relevance questionnaire asking participants whether the
PTSD checklist they completed was “highly relevant” to their
lived experience. Participants were given space to elaborate on
their yes/no response. The meaning of “highly relevant” was left
open to participant interpretation. Responses were expected to
indicate whether the PTSD checklist described experiences that
were germane to participants’ psychological response to violence
and displacement, and as such, whether they might deserve clinical
attention. The questionnaire also asked whether any of the check-
list items were difficult to understand, because failure to under-
stand questionnaire items would jeopardize the potential relevance
of the survey.
Analytic Approach
SPSS for Windows, version 16.0, was utilized to calculate
symptom levels, bivariate correlations between symptom levels
and demographic factors, and regression analyses. Open-ended
responses on the PTSD Checklist Relevance questionnaire were
reviewed, and the range of responses were coded and then grouped
into smaller categories for presentation. For the purposes of this
study, focus group analysis was restricted to the final segment of
the focus groups, in which participants described and discussed
subjective treatment needs. Nvivo statistical software was utilized
to organize the transcribed material and to assign and manage
codes and categories. The analytic approach involved five major
steps which were conducted by the co-Principal Investigator based
4 RICHARDS ET AL.

on methods recommended by Miles and Huberman (1994) for as Afro-Colombian. There were more women than men in the
single coders and by Creswell (2007) for the general analytic sample, and most participants reported being either single, in a
approach. First, the transcripts were read and reread to obtain a domestic partnership, or married. Educational attainment was
gestalt understanding of the material. Second, two major catego- fairly low with the majority reporting either no formal education or
ries of statements that reflected focus group material and the some primary school education.
researchers’ primary areas of interest were identified. These cate-
gories included (a) statements in which participants suggested PTSD
types of interventions or gave their opinion about interventions
suggested by the group leaders and (b) statements in which par- Surveys of three participants were eliminated because they did
ticipants described the purpose or mechanism of action of an not endorse a recent criterion A1 event. Surveys of three additional
intervention. The third step involved sentence-by-sentence review participants were eliminated when calculating the total PTSD
of the transcripts and assignment of codes to the data. This step checklist score because of missing data. Of the remaining 103
involved three passes through the transcripts to ensure that relevant subjects, 91 (88.3%) exceeded the cut-off score for a PTSD diag-
information was coded. In the fourth step, related codes were nosis. The mean PTSD checklist score for these 103 subjects was
merged into a smaller yet representative set of themes. These 68.9 (SD ⫽ 14.3), comparable to the mean score of 70.4 (SD ⫽
themes were then assigned to the above-mentioned categories for 22.9) reported by Pineda and colleagues in patients with PTSD as
presentation. diagnosed by SCID interview (Pineda et al., 2002). Eighty-four
(81.6%) reported impairment in relationship and/or occupational
Results functioning. When the PTSD checklist responses were analyzed by
symptom clusters, 61 (59.2%) of 103 participants met full symp-
The demographic characteristics of the full sample of 109 par- tom criteria (fulfilled clusters A, B, C, and D) and also endorsed
ticipants are summarized in Table 1. The vast majority (84%) of impairment in relationship and/or occupational functioning.
participants self-identified as mestizo, whereas 21% self-identified Female gender was a significant correlate of higher PTSD
checklist score after controlling for other demographic variables,
including age, ethnoracial status, marital status, highest education
Table 1 grade, employment status, and time since arrival in Medellı́n (B ⫽
Demographic Characteristics and PTSD, Anxiety, and 9.00, ␤ ⫽ .30, t ⫽ 2.46, p ⫽ .016). No other demographic
Depression Scores in the Sample (n ⫽ 109) variables, including ethnoracial status, were significantly corre-
lated with PTSD scores. When the sample was divided into groups
Age (years; M[SD]) 37.81 (14.3)
Gender (n[%])
by time since arrival in Medellı́n, we found no significant differ-
Male 44 (40.4) ence in PTSD checklist scores between individuals reporting being
Female 65 (59.6) displaced less than a month, more than a month but less than 1
Ethnoracial status (n[%]) year, and 1 year or more prior to study evaluation.
Mestizo 84 (77.1)
Afro-Colombian 23 (21.1)
Other 2 (1.8) Anxiety Symptoms
Marital status (n[%])
Married 19 (17.4) The mean score for the Zung Anxiety Scale was 47.69 (SD ⫽
Single 30 (27.5) 8.21). This reflects a mild to moderate level of anxiety on average.
Domestic partner 35 (32.1)
Separated 13 (11.9)
Fifty-nine participants (54.1%) fell into the mild to moderate
Widowed 9 (8.3) range, whereas six participants (5.4%) reported symptoms consis-
Missing data 3 (2.8) tent with severe anxiety. Although the group as a whole only
Educational attainment (n[%]) reported mild-to-moderate levels of general anxiety symptoms, a
No formal education 14 (12.8) significant proportion reported that anxiety symptoms resulted in
Some or all primary school 47 (43.2)
Some or all secondary school 37 (34.0) social and/or occupational impairment. In fact, 74 respondents
Some university training 2 (1.8) (67%) reported that anxiety symptoms resulted in at least some
Missing data 9 (8.3) impairment in relationship functioning, and 78 respondents
Employment status (n[%]) (71.6%) reported that anxiety symptoms impaired their ability to
Employed 5 (4.6)
Unemployed 104 (95.4)
work or to look for work. No demographic variables, including
Time since displacement (n[%]) gender and ethnoracial status, were significant predictors of Zung
Less than 1 month 41 (37.7) anxiety scores.
More than 1 month but less than 1 year 39 (35.8)
More than 1 year 24 (22.0)
Missing data 5 (4.6) Depression Symptoms
PTSD Checklist score (M[SD])ⴱ 68.9 (14.3)
Exceed diagnostic cut-off (n[%])ⴱ 91 (88.3) The mean score for the Zung Depression Scale was 48.54 (SD ⫽
Zung Anxiety Scale score (M[SD]) 47.7 (8.2) 9.02), which falls short of the threshold of 50 which indicates
Exceed diagnostic cut-off (n[%]) 65 (59.5) clinically relevant depression. However, 45 participants (41%)
Zung Depression Scale score (M[SD]) 48.5 (9.0)
Exceed diagnostic cut-off (n[%]) 45 (41.3)
scored above 50, among whom 34 participants (31%) had scores
consistent with mild depression, 10 (9%) had scores consistent
ⴱ
N ⫽ 103. with moderate depression, and one individual reported symptoms
 PSYCHOSOCIAL SEQUELAE OF CONFLICT IN COLOMBIA 5

suggestive of severe depression. Furthermore, 67 respondents
(61.5%) reported at least some impairment in relationship func-
tioning because of their symptoms, and 78 subjects (71.6%) re-
ported at least some impairment in their ability to work or look for
a job as a result of their depression symptoms.
Analysis of the demographic predictors of Zung depression
scores showed that female gender (B ⫽ 6.12, ␤ ⫽ .34, t ⫽ 3.06,
p ⫽ .003), higher education (B ⫽ .67, ␤ ⫽ .27, t ⫽ 2.28, p ⫽
.025), and being separated as opposed to married (B ⫽ 8.31, ␤ ⫽
.29, t ⫽ 2.28, p ⫽ .025) were significant predictors of higher
depression score in a regression model including other demo-
graphic variables. The relationship between depression score and
Afro-Colombian, as opposed to mestizo, ethnoracial status nearly
reached significance when controlling for the other aforemen-
tioned demographic variables (B ⫽ 4.74, ␤ ⫽ .20, t ⫽ 1.92, p ⫽
.058).
PTSD Checklist Relevance
Out of 109 total participants, 92 (84%) reported that the PTSD
checklist was not difficult to understand, whereas 17 (16%) re-
ported that one or more questions were difficult to understand.
None of the participants expanded on their yes/no response. When
asked if the PTSD checklist was highly relevant to their personal
experience 94 respondents (86%) responded “yes,” 9 (8.5%) re-
sponded “no,” and 6 (5.5%) did not respond to this item. Fifty-
three respondents (48.6%) either wrote or dictated a narrative
explaining why they thought the questionnaire was or was not
highly relevant to their life experience. By far, the most common
explanation for participants’ endorsement of the questionnaire as
highly relevant was that the items closely described their experi-
ences, both physical and emotional (stated by 36 respondents). Six
respondents provided a detailed description of personal experi-
ences of threats and violence. Seven participants stated with less
detail that the questionnaire items reflected their overall experi-
ence of violence or the disruption in their lives resulting from
displacement. Eleven participants described specific symptoms
they were experiencing, including avoidance of memories of up-
setting events, hypervigilance, hyperactive startle reactions, fear
and anxiety, and persistent painful memories. Seven participants
described a feeling of pervasive sadness that would not go away as
well as expectation that they would never forget certain experi-
ences. Five participants requested psychological support and/or
alluded to wanting to help others in a similar condition.
Psychosocial Treatment Needs as Identified in
Focus Groups
Results from focus groups were indicative that internally dis-
placed Colombians in Medellı́n who seek services at the UAO
recommend treatment intervention for mental health problems
resulting from armed conflict and displacement. The most com-
mon spontaneously recommended resource in all focus groups was
a psychologist. The most common recommendation other than
speaking with a psychologist was that of group gatherings
(“reuniones” as described by focus group members in Spanish).
These gatherings would range from more structured forums in
which a leader would provide psychoeducation and guidance to
informal social gatherings for displaced individuals organized by
institutions like the UAO. Group members also recommended
other potentially useful interventions and/or resources, including
psychoeducational material in books, videos, pamphlets, or
through TV and radio programs. More sparsely represented ideas
included massage, evaluation by medical professionals to make
sure nothing was physically wrong, and talking to priests.
Models of Intervention as Described by Focus
Group Participants
With the goal of gaining a better understanding of what models
of therapeutic intervention would be acceptable to internally dis-
placed Colombians, we identified statements in which the purpose
and/or mechanism of the intervention was described. From 161
statements, 31 codes initially emerged. These were then narrowed
down into nine broader codes, or themes, described in Table 2. The
most common theme by far describes the therapeutic intervention
in terms consistent with a supportive type of therapy. In most
cases, participants were referring to an in-person therapy or group
therapeutic activity. The intervention would primarily provide a
forum for being listened to, for venting, for feeling understood and

Table 2
Categories Describing Models of Therapeutic Intervention Suggested by Group Participants

Category Category description

Supportive therapy
Cognitive-behavioral or
behavioral therapy
Recreation and distraction
Community building
Material support
Drug treatment
Psychoeducation
Role recovery
Outreach
Forum for being listened to, understood, encouraged—either with a trained
professional or in a group setting
Skilled professional who guides person to assimilate and/or forget traumatic
experiences and/or learn skills to relieve symptoms
Activities that distract individuals from daily stressors, distressing thoughts
and memories, and allow them to relax
Activities that decrease sense of loneliness, experiences of discrimination,
and create sense of belonging and of community
Intervention addresses material needs and provides job training
Treatment of mental health symptoms by a medical professional
Psychoeducation using TV, radio, video, and/or written material
Intervention that provides specific guidance in rebuilding one’s life: through
occupational training and developing “proyecto de vida”
Intervention accesses distressed individuals who don’t seek treatment due to
stigma or other barriers
6 RICHARDS ET AL.
valued, for regaining morale and hope, or in the words of one
participant, to get grounded.
Several participants specifically assigned the task of healing to
a professional trained to address psychological issues. Within that
framework, several participants described what they thought the
mechanism for healing by a trained professional would be. For
example, one participant emphasized the importance of “detoxify-
ing” one’s mind and “assimilating” past events so that they would
lose their psychological impact, an understanding rather aligned
with trauma-focused cognitive– behavioral approaches. He said,
“With regard to all we’ve talked about, to detoxify the mind, the
most appropriate person is a psychologist, to help one assimilate
things. . . .As I was saying before, one doesn’t forget; the events
just lose their impact.” Other participants described the therapy as
a means to “clear one’s head” of distressing thoughts and experi-
ences, in some cases with the goal of essentially forgetting the
distressing events that had occurred. Several participants spoke of
the role of the skilled professional as prescribing activities or
behaviors they could engage in to alleviate particular symptoms,
somewhat similar to a more behavioral approach.
Several participants suggested that interventions involving dis-
traction and recreation would allow individuals to forget their daily
stressors, distract them from distressing thoughts and memories,
and allow them to relax. For example, one individual stated:
“The worst is to have an idle mind and not have anything to
do. . .. The only thing I can do is to start thinking about the
memories that I still have, and those are bad memories. Because in
those memories is everything I went through with the people I
loved who are no longer alive. . ..”
Organized recreational and social activities were also described
as therapeutic because they would create opportunities to share
psychoeducational knowledge and practical survival tips. Perhaps
most importantly, group members stated these activities would
decrease the sense of being alone, of being ostracized, and would
enable displaced individuals to develop a sense of community. For
example, one participant stated, “[It would be nice to convene in a
place] and hang out with people like me. So as not to feel
so. . .insignificant. . .. Because here one really feels looked down
upon.” In line with this, some expressed comfort and enthusiasm at
the idea of belonging to a community of displaced people.
“Let’s say, I think that we’re, that we’re, that we’re not of say
Afro-Colombian culture, or indigenous culture, nor. . ..one could
say that our culture is that of the displaced, this would be like our
region. There’s a displaced person, I’m a displaced person. He’s no
longer Black, I’m not Black, that guy isn’t either—we’re all
displaced people.”
Another member expressed the increase in trust and ability to
share when in the company of people with similar experiences. He
said, “Things change immediately with a group, that is, people
who’ve been through the same as you. Trust—that changes—
people feel less inhibited about talking about things.” This phe-
nomenon was made manifest during the focus group themselves. A
large percentage of members of all groups spontaneously ex-
pressed a sense of relief, a feeling of being supported, and grati-
tude for being listened to, during the focus groups.
The importance of material support was also emphasized by
group participants. One woman emphasized that emotional and
occupational support need to go hand-in-hand, as “venting” would
be of limited utility if one’s family’s basic needs were unmet.
Many individuals emphasized the importance of occupational
training as a distraction from traumatic memories as well as a
means to rebuild one’s life in a completely new environment for
which most displaced people have not been prepared. They also
described this as a way to relieve the feelings of shame related to
handouts and being treated like invalids. This participant’s state-
ment was endorsed by many: “What I want is for nobody to be
giving me food because I can earn it on my own. Be-
cause. . .because getting handouts makes you look and feel like an
invalid.”
Several interventions, primarily therapies and psychoeduca-
tional interventions through various media, were described as
useful in that they would help individuals gain a better understand-
ing of their emotional experiences and would help them to find
solutions to their problems. Although rarely mentioned, some
participants suggested drug treatment to relieve symptoms such as
insomnia and anxiety.
Group members also gave their opinion on Internet-based treat-
ment programs, a form of intervention of interest to the group
leaders. The responses ranged from enthusiasm about this ap-
proach to concern about limited access due to financial constraints,
technical skill, and illiteracy. However, several participants en-
dorsed enthusiasm for programs that would combine literacy and
technical training with a psychotherapeutic component.
Finally, several individuals suggested the importance of out-
reach to internally displaced people. Although participants identi-
fied stigma as the primary indication for outreach interventions, a
range of barriers emerged as additional themes in focus group
discussions. The impediments to accessing psychological support
fell into four major categories: stigma or fear of being labeled as
“crazy;” lack of care provider time to provide adequate services;
fear of discovery when revealing one’s personal experiences; and
lack of access and technical ability to utilize services. The fear of
stigma was primarily associated with seeing a psychiatrist; how-
ever, seeing any mental health provider was considered stigmatiz-
ing by some. For example, one participant said, “Someone might
say to another person—‘hey, let’s see a psychologist.’ [The re-
sponse would be:] ‘Me? What am I going to see a psychologist
for? You think I’m crazy?’” One individual who felt strongly that
displaced individuals should be obligated to attend meetings with
psychologists stated, “People are ignorant because they don’t have
access to the information. That’s why they’re afraid, that’s why
they run away from the people who can empower and help them.”
Discussion
Our findings demonstrate high levels of PTSD, depression, and
anxiety symptoms in the sample. Findings from a systematic
meta-analysis of PTSD and depression in populations affected by
armed conflict indicate that nonrepresentative samples, smaller
sample size, and assessments using self-report measures are meth-
odological factors which contribute to elevated rates of PTSD and
depression (Steel et al., 2009). These three factors likely affected
the elevated scores in this study. However, the meta-analysis also
identified substantive factors that contribute to high rates of de-
pression and/or PTSD, including degree of exposure to violence,
experiences of torture, a source conflict that is ongoing, the general
state of politically motivated violence in the country, and displace-
ment. Although we do not have measures assessing the former two
 PSYCHOSOCIAL SEQUELAE OF CONFLICT IN COLOMBIA
variables, all internally displaced Colombians are exposed to the
latter three predictors. These factors may very well contribute to
the elevated symptom reports in the sample. The fact that 88% of
the sample scored higher than the cut-off score for PTSD and 59%
met full criteria for PTSD based on analysis by symptom clusters
provides reason for concern and indicates a need for further
evaluation.
Other studies have demonstrated that social and economic fac-
tors, including social isolation and unemployment, contribute to
mental distress in survivors of mass conflict and displacement
(Johnson & Thompson, 2008; Roberts, Damundu, Lomoro, &
Sondorp, 2009; Roberts, Ocaka, Brown, Oyok, & Sondorp, 2008).
Although we did not formally assess social support, the focus
group discussions provide evidence that such support was lacking
and that this might contribute to elevated symptom levels. Because
unemployment characterized the occupational status of the vast
majority of participants we could not detect an effect, but it is
possible that this also contributed to high symptom levels. With
respect to marital status, several studies in the U.S. and abroad
indicate that being married is a protective factor for mental illness
(Roberts et al., 2008). Consistent with this, we found that being
separated as opposed to married was a predictor of higher depres-
sion scores.
Finally, although high rates of acute stress or posttraumatic
stress symptoms might be considered normal shortly after dis-
placement, and do not necessarily predict future or persistent
PTSD (Bryant, Creamer, O’Donnell, Silove, & McFarlane, 2008),
we did not find any difference in symptom levels between indi-
viduals displaced more than a year compared to individuals dis-
placed less than a year prior to the evaluation.
On the whole, the data suggest that participants experienced
higher levels of clinically significant PTSD symptoms as com-
pared to depression and anxiety symptoms. The vast majority
(88%) of participants exceeded the diagnostic cut-off score for
PTSD, with a mean score far exceeding that cut-off score. In
contrast, the mean depression score fell just short of the cut-off for
clinical significance and the mean anxiety score just surpassed the
level of clinical significance. This finding may be explained by the
greater degree of specificity of PTSD for the nature of distress
experienced by individuals affected by trauma. Responses to the
open-ended PTSD Checklist Relevance questionnaire indicate that
participants experienced a number of symptoms that are specific to
PTSD, including hypervigilance and hyperactive startle reactions.
Nonetheless, that 41% of the sample scored in the range of
clinically significant depression and that 59% of participants en-
dorsed clinically significant levels of anxiety suggest that these
categories of mental illness are also worthy of attention.
The higher levels of PTSD and depression symptoms among
women in this sample support the literature indicating that world-
wide, civilian women are at greater risk of developing PTSD than
men. Research on populations affected by armed conflict and
displacement also demonstrates such a gender difference in levels
of psychiatric distress (Caceres et al., 2002; Johnson & Thompson,
2008; Ranasinghe & Levy, 2007; Roberts et al., 2009; Roberts et
al., 2008). Although the basis for such differences is not clear,
greater peritraumatic emotionality in civilian women is a potential
explanation for gender differences in PTSD (Lilly, Pole, Best,
Metzler, & Marmar, 2009). It has also been suggested that men
may express distress through higher levels of somatization, higher
7
levels of substance abuse, and higher levels of externalizing be-
havioral disorders (Kessler et al., 2005; Lilly et al., 2009). Twelve
of the 20 items in the Zung Anxiety questionnaire describe somatic
symptoms (as opposed to 5 of 20 in the Zung Depression ques-
tionnaire), such that a higher degree of somatization among men
may balance out with higher levels of nonsomatic anxiety symp-
toms in women and explain the similar levels of total anxiety
symptom scores among men and women in the sample. Epidemi-
ological research in Colombia also indicates that rates of substance
use disorders in men far exceed rates in women (Posada-Villa et
al., 2009). Because alcohol use is a socially acceptable behavior in
Colombia, especially among men, substance use may be a rela-
tively nonstigmatizing way of coping with and numbing psycho-
logical distress (Ávila Cadavid, Escobar Córdoba, & Chica Urzola,
2005). Assessments of distress based solely on assessments of
PTSD, depression, and anxiety may therefore underestimate dis-
tress in men.
We did not find that ethnoracial status predicted PTSD or
anxiety symptom levels in our regression model. However, we did
find a trend association between Afro-Colombian ethnoracial sta-
tus and higher depression scores. Research indicates that very large
sample sizes are necessary to detect race/ethnic differences in
PTSD rates (Brewin et al., 2000). Research in the U.S. suggests
that a higher degree of exposure could explain findings indicating
higher PTSD rates among Blacks as opposed to Whites (Hunter &
Schmidt, 2010; Pole et al., 2008). Given the lack of attention to
ethnoracial status and mental health in Colombia, and given the
higher vulnerability of Afro-Colombians and non-White Colom-
bians to political violence and forced displacement, we believe this
topic deserves further exploration. With respect to Hispanic eth-
nicity in general, research in the U.S. indicates that Hispanics may
be at higher risk of PTSD than non-Hispanic Whites. The elevated
PTSD symptom levels in this study may therefore reflect a higher
risk of PTSD in Hispanics in general. On the other hand, epide-
miological research does not support higher rates of PTSD in the
general Colombian population compared to the general U.S. pop-
ulation (Kessler et al., 2005; Posada-Villa et al., 2009).
An unexpected finding was the relationship of higher educa-
tional attainment with higher depression symptoms. Higher edu-
cational attainment has generally been shown to be protective
(Brewin et al., 2000; Caceres et al., 2002; Shalev, Peri, Canetti, &
Schreiber, 1996). A potential explanation for this finding is that
individuals from rural areas with a higher education may have
expected a certain degree of occupational and social stability to
result from their education and therefore might experience a
greater sense of loss when those expectations were shattered by
experiences of violence and displacement. Such findings deserve
further exploration.
The focus group discussions revealed great interest in psycho-
logically based interventions for PTSD. The strong interest in
supportive-type therapies and the positive response to the focus
groups themselves suggest at least some role for supportive group
therapy. Additionally, some participants, despite lack of formal
education, were very articulate in describing mechanisms by which
therapies might aid individuals to process traumatic experiences.
The interest in receiving support from psychologists as well as
descriptions of cognitive and behavioral mechanisms for healing
suggests an important potential role for trauma-focused, evidence-
8 RICHARDS ET AL.
based therapies in the treatment of internally displaced Colom-
bians.
The focus groups also highlighted the importance of redevelop-
ing social networks for displaced people, as so many participants
discussed group gatherings of various sorts as therapeutic. These
focus groups revealed that there is a longing to recreate a sense of
community but that individuals find themselves isolated and fear-
ful to do so, either because of a hypervigilance and mistrust
attributable to prior traumatic experiences and/or because of the
reality of ongoing danger in their current environments.
Group members also described groups as therapeutic through
their ability to distract displaced people from unpleasant memo-
ries. It is possible that this interest in distraction as a form of
therapy reflects an avoidant coping strategy, which would be
consistent with a diagnosis of PTSD. Such a coping strategy could
jeopardize adherence to trauma-focused therapies. On the other
hand, this may also reflect participants’ lack of knowledge about
the mechanisms of effective treatments for psychological problems
or a lack of confidence that such therapies are available to them.
Finally, such an interest in distraction may also reflect an intuitive
awareness that some displaced people may not experience the
degree of safety and social and emotional stability needed to
engage in exposure-based therapies.
The issue of stability highlights what should be considered an
obvious point when dealing with populations affected by armed
conflict and displacement: psychological support is an impor-
tant but partial component of intervention programs. Interven-
tion programs should recognize and address, as much as pos-
sible, the material needs of the communities through housing
assistance, occupational and literacy training, food support,
childcare, and general medical care. These are all challenges
with which the Colombian government and global communities
working with immigrants and geographically displaced people
must contend.
There are several limitations to this study. This study inter-
viewed a convenience sample of individuals seeking support
from a government and NGO co-administered center. Although
this is the central resource center for internally displaced people
in Medellı́n, some displaced Colombians are not referred or
choose not to seek services due to a desire for anonymity, lack
of resources to travel to the center, or other reasons. Although
individuals and families who are adapting well after displace-
ment may not seek services at the UAO, which would indicate
that this study overestimates distress, the most psychologically
distressed individuals may also not have the wherewithal to
seek services, in which case survey results would underestimate
distress. This service-seeking population cannot be considered
representative of the displaced population in Colombia. As
mentioned previously, indigenous groups are largely absent in
the population. Afro-Colombians were also relatively few in
number. Anecdotally, the researchers noted that Afro-
Colombians were less highly represented at the UAO during the
months of study implementation as contrasted with the prior
year. This may simply reflect the fluctuations in the geography
of violence and displacement at any given time. Although
literacy and educational attainment were fairly low, people able
to come all the way to Medellı́n may also have more education
and economic resources than many displaced people from rural
areas, and therefore may not be culturally representative of
most internally displaced Colombians. Additionally, because
we oversampled Afro-Colombians and men for our focus
groups, the focus group sample cannot be considered represen-
tative of the larger sample of survey respondents.
The project was also limited by the use of self-report question-
naires. Although the PTSD checklist had been validated in a
Colombian population directly affected by the armed conflict, a
few participants described difficulty in understanding the question-
naire, and many required assistance from research staff, which
may in some cases have biased their responses. Furthermore, to
ensure privacy and minimize potentially upsetting disclosures of
trauma experiences, we did not inquire about the details of trau-
matic experiences using quantitative measures, although we did
allow such information to be disclosed spontaneously in focus
groups. Prior to testing any trauma-focused interventions, it will be
paramount to better evaluate the nature of traumatic experiences
and PTSD diagnoses in internally displaced people.
The focus groups may also have been affected by bias. It is
likely that focus groups led by a psychologist and a psychiatrist
will favor positive endorsement of psychological interventions,
especially among individuals who may be eager to garner any
support they can for their suffering. On the other hand, participants
had little difficulty in expressing their reservations about psychi-
atrists, whom they viewed as primarily caring for “crazy” people.
Their ability to discuss this in the presence of a psychiatrist
supports the authenticity of their remarks.
Conclusions
This study reveals high levels of mental distress in a sample of
internally displaced Colombians. It also demonstrates the useful-
ness of the PTSD construct in describing experiences that study
participants consider worthy of intervention. A high interest in
therapy with psychologists and other skilled clinicians suggests an
important role for trauma-focused treatments, which may be most
beneficial when implemented in the context of broader interven-
tions aimed at psychosocial rehabilitation. Active outreach by
mental health professionals may also be useful in overcoming
stigma-related barriers to help-seeking in this population. Given
the large fraction of the Colombian population affected by armed
violence and forced displacement, these findings call for further
investigation of treatment needs and greater investment into psy-
chosocial interventions for internally displaced Colombians. These
findings may also be used to guide intervention studies in other
conflict-affected populations.
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